Inside Health

Flawed Care for Head Injuries Found

By GINA KOLATA

Published: October 16, 1991

MEDICAL treatment for the 150,000 Americans each year who suffer severe head injuries is often so outdated that patients are more likely than not to receive treatments that could hurt them more than help. As a result, people are being left with permanant brain damage that could have been avoided.

This bleak picture is disclosed by a new national survey of trauma centers that provides the first extensive look at how intensive care units treat patients who lapse into comas from severe head injuries. Half of these patients die, and most of the rest are left with brain damage and often-severe disabilities.

The care these patients receive in the first week after injury can make the difference between life and death or between a life of total dependency and a return to work. Yet the new study shows that many centers ignore the monitoring procedure recommended in textbooks and apply two methods of treatment that most experts regard as useless or worse.

The study, conducted by the Brain Trauma Foundation, a private organization that finances research on head injuries, shows that treatments vary widely from hospital to hospital. It has not yet been published, but the researchers say they will present the results at the annual meeting of the American Association of Neurosurgeons in April and agreed to discuss them because of their importance. Possibly Harmful Practices

The group randomly selected 277 trauma centers in 45 states, and 261 participated in the survey, conducted by telephone by specialty nurses. Among the main findings were these:

*Only a third of the trauma centers routinely monitored the pressure inside the head that results when an accident causes the brain to swell; yet textbooks and leading head trauma researchers say such monitoring is essential.

*Ninety-five percent of the centers have patients hyperventilate, making them breathe rapidly and shallowly, to reduce the pressure in the head; most experts consider the practice dangerous because it reduces blood flow to the brain.

*Seventy-nine percent of the centers give patients steroids, though studies have repeatedly shown they do not help and may harm.

"The data are alarming," said Ralph Isham, the director of the Brain Trauma Foundation.

Dr. Robert Hariri of Cornell University Medical Center, who helped design the survey, said, "We were really shocked." The study showed neurosurgeons at trauma centers "are not taking advantage of the current state of knowledge in the field," he said, and that "patients are being allowed to develop irreversible brain damage that could have been avoided."

In contrast said Dr. Jamshid Ghajar, a neurosurgeon at Cornell Medical College who was an author of the report, virtually every other subspecialty has established guidelines for treatment. "If we did the same poll of those hospitals and asked how they treat general trauma patients, I'm sure they'd be very uniform," he said.

Neurosurgeons at research centers said they were taken aback by the new findings. "I am surprised," said Dr. Byron Young, chief of neurosurgery at the University of Kentucky Medical School. Importance of Research

"It's an important study,' said Dr. Richard Saunders, chairman of neurosurgery at Dartmouth University School of Medicine. It shows, he said, that "things are being done perhaps for the sake of doing something," and not because they have been shown to help.

Head injury statistics are disheartening, neurosurgeons say. The typical patient is a young man who struck his head in an auto accident, lost consciousness and slipped into a coma. Others are children who fell off bikes without helmets, adults who were in motorcycle accidents or pedestrians struck by cars.

Severe head injury is the leading cause of death for people under 45 years old. The survivors are usually permanently affected: their memory is never normal again, or they are paralyzed on one side of the body, or their intelligence is not quite what it used to be.

Head injury is a leading cause of epilepsy in this country, resulting in 5,000 cases a year. And it is a prominent cause of mental illness, because it damages brain centers that control the aggressaion and emotion. 'A Major National Problem'

"What we are dealing with is a major national problem," said Dr. Murray Goldstein, director of the National Institute of Neurological Diseases and Stroke.

Brain damage often occurs because the brain starts to swell after an accident, pressing delicate tissue against the unyielding skull. Dr. Anthony Marmarou of the University of Virginia School of Medicine found that 80 percent of patients with serious head injury had brain swelling.

For that reason, most leading neurologists keep careful track of the pressure inside the heads of all their comatose patients and take measures to lower it if it starts to soar. For example, they can drain cerebrospinal fluid through a catheter.

But the survey found that only a third of trauma centers routinely monitor the pressure inside patients' head. The researchers defined routine monitoring as monitoring the pressure for at least 75 percent of comatose patients.